Early REperfusion Therapy with Intravenous Alteplase for Recovery of VISION in Acute Central Retinal Artery Occlusion (REVISION): Study Protocol of a Phase III Trial

RATIONALE

Meta-analyses of case series of non-arteritic central retinal artery occlusion (CRAO) indicate beneficial effects of intravenous thrombolysis when initiated early after symptom onset. Randomized data is lacking to address this question.

AIMS

REVISION investigates intravenous alteplase within 4.5 hours of monocular vision loss due to acute CRAO.

METHODS

Randomized (1:1), double-blind, placebo-controlled, multicenter adaptive phase III trial.

STUDY OUTCOMES

Primary outcome is functional recovery to normal or mildly impaired vision in the affected eye defined as best corrected visual acuity of the Logarithm of the Minimum An-gle of Resolution of 0.5 or less at 30 days (intention-to-treat analysis). Secondary efficacy out-comes include modified Rankin Score at 90 days and quality of life. Safety outcomes include symptomatic intracranial hemorrhage, major bleeding (International Society on Thrombosis and Haemostasis definition) and mortality. Exploratory analyses of optical coherence tomogra-phy/angiography, ultrasound and MRI biomarkers will be conducted.

SAMPLE SIZE

Using an adaptive design with interim analysis at 120 patients, up to 422 participants (211 per arm) would be needed for 80% power (one-sided alpha 0.025) to detect a difference of 15%, assuming functional recovery rates of 10% in the placebo arm and 25% in the alteplase arm.

DISCUSSION

By enrolling patients within 4.5 hours of CRAO onset, REVISION uses insights from meta-analyses of CRAO case series and randomized thrombolysis trials in acute ischemic stroke. Increased rates of early reperfusion and good neurological outcomes in stroke may trans-late to CRAO with its similar pathophysiology.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04965038; EU Trial Number: 2023-507388-21-00.

Intravitreal Injections: Improving Sustainability by Reducing Clinical Waste

BACKGROUND

Intravitreal injections are one of the most commonly performed ophthalmic procedures. It is estimated that over 1 million intravitreal injections are performed in Germany annually. The aim of this study was to quantify the waste and carbon footprint associated with single-use injection sets, and to establish a waste reduction strategy.

MATERIAL AND METHODS

The clinical waste and associated carbon footprint from standard disposable injection sets used by tertiary referral centres in Germany (n = 6) and the United Kingdom (n = 2) were assessed. The safety of performing intravitreal injections with a minimalistic material-sparing approach was evaluated.

RESULTS

The average weight of an injection set (and hence the waste generated from each injection) was 165 g. On average, each injection set comprised 145 g (88%) of plastic, 2.1 g (1.3%) of metal, 4.3 g (2.6%) of paper, and 12.9 g (7.8%) of gauze/swabs. The production of such injection sets was extrapolated to a CO2 equivalent of 752.6 tonnes (t), and the incineration of the resulting waste to a CO2 equivalent of 301.7 t. For 1 million injections, this equates to 145.2 t of plastic, 2.1 t of metal, 4.3 t of paper, and 12.9 t of gauze/swabs. A material-sparing approach can reduce injection set-associated waste by 99% without necessarily compromising patient safety.

CONCLUSION

A resource-saving approach to intravitreal injections can minimise the generation of clinical waste and its associated carbon footprint, thereby supporting sustainability.

[Surgical therapy and pathogen detection in endogenous endophthalmitis : Analysis of data from five German eye hospitals]

BACKGROUND

Endogenous endophthalmitis results from hematogenous spread of bacterial or fungal infection in severely diseased patients. Specific systemic and intraocular therapy is required. The basis for this treatment is causal pathogen detection in blood culture or vitreous sample. However, functional results are limited.

OBJECTIVE

The current article provides practical hints for surgical therapy and pathogen detection in patients with endogenous endophthalmitis.

METHODS

A retrospective analysis of anonymous data of 68 male and female patients from 2018-2023 from five ophthalmology clinics in Germany was performed.

RESULTS

Mean age of affected patients was 71.4 years (31-96 years). Surgical therapy included pars plana vitrectomy (ppV) and intravitreal injection (IVOM). In 44 of 68 patients (65%), 1-3 surgeries were performed, 4-6 surgeries were required in 14/68 (21%) of patients, and 10 or more surgeries were required in 4/68 patients (6%). Pathogen detection was possible in 34% of vitreous specimens and in 11% of anterior chamber samples. Mean initial visual acuity was logMAR 1.5. After treatment and a mean follow-up of 2.5 months, mean visual acuity was logMAR 1.3. Preanalytical methods for specimen collection like the Freiburg endophthalmitis set to optimize pathogen detection are presented.

CONCLUSION

Severe inflammatory intraocular reactions in endogenous endophthalmitis necessitate a combination of ppV and repeated IVOM. In addition to providing a vitreous sample, ppV also serves to remove inflammatory fibrin membranes. Early pars plana vitrectomy with specific antibiotic or antifungal therapy should be sought in addition to the focus search and systemic therapy.

[Chronic eye pain]

Numerous conditions in the field of ophthalmology are associated with pain in or around the eye. Chronic pain associated with the eye is a common finding in the daily routine of ophthalmologists and can be associated with primary ocular or extraocular diseases as well as with other conditions. Appropriate diagnostic assessment and management of people with chronic pain requires an understanding of the condition based on the biopsychosocial model in which the interactions of biological/somatic, psychological and social factors are determining pain and suffering. Beyond the ophthalmological findings,  close interdisciplinary cooperation and assessment are required. Therefore, if eye pain is insufficiently responsive to treatment or if symptoms of chronic pain are evident, pain medicine expertise should be involved. The management of chronic ocular pain is based on interdisciplinary multimodal approaches, in addition to the ophthalmologist-specific approaches. These focus on self-efficacy, patient competence and acceptance of pain as central goals of treatment rather than pain relief. Patient information, education and the development of a suitable concept by the interdisciplinary team are essential therapeutic aspects in this context.

[Internistic clarification of retinal vascular occlusions]

Retinal vascular occlusions require close cooperation of different medical disciplines to ensure optimal care of the affected patients. The medical clarification between arterial and venous occlusions is comparable but in the case of retinal arterial occlusions it should be carried out immediately. The most important associated diagnoses are arterial hypertension, diabetes mellitus, dyslipidemia, and atrial fibrillation. In younger patients and in the absence of risk factors, a search for rarer causes should be carried out giant cell arteritis in particular should be excluded. In both types of occlusions a causative glaucoma must also be considered.

Retinal Vascular Occlusion and Underlying Generalized Vascular Diseases

Retinal vascular occlusion not only threatens vision loss but is also associated with other systemic risk factors and vascular diseases. Interdisciplinary cooperation is of great importance in these patients. The risk factors hardly differ between arterial and venous retinal occlusions, which is due to the special anatomy of retinal vessels. Major underlying conditions associated with retinal vascular occlusion include arterial hypertension, diabetes mellitus, dyslipidemia, cardiac disease, particularly atrial fibrillation, or vasculitis of large- and middle-sized arteries. Every new diagnosed retinal vascular occlusion should therefore be taken as an occasion to search for risk factors and possibly adjust an already existing therapy in order to prevent further vascular events.

Benefit of intravitreal injections in patients with sub-threshold baseline visual acuity: a retrospective single-centre study

PURPOSE

To investigate the lower visual acuity threshold for recommending intravitreal injection therapy (IVI). The lower limit of 1.3 logMAR best-corrected visual acuity (BCVA) was adopted in 2006 and has been maintained since then.

METHODS

In this retrospective study, data from patients with a logMAR BCVA ≤ 1.3 and 24 months follow-up were analysed. We included patients with neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DME), or retinal vein occlusion (RVO).

RESULTS

The data from 164 patients (nAMD: 107; DME: 15; RVO: 42) were analysed. We observed a significant improvement at all time intervals (0 to 6, 6 to 12, 12 to 18, and 18 to 24 months after initiating IVI) compared to baseline. Across all indications, median BCVA improved from 1.4 to 1.0 within the first 6 months and remained stable within 24 months. Patients received a median of 5 and 10 injections within 6 and 24 months, respectively. Median foveal retinal thickness was 594.5 μm at baseline and dropped to 244.5 μm, 235.5 µm, 183 µm, and 180 µm during the four consecutive time intervals.

CONCLUSION

Patients with nAMD, DME, and RVO with poor baseline BCVA may also benefit from intravitreal therapy with VEGF-inhibitors. In the present study, we observed functional and morphological improvement over 2 years irrespective of the underlying macular disease. Those patients should not be excluded from therapy.

[Identifying patients with risk for severe pain after ophthalmological surgery]

Modern ophthalmology includes a wide range of surgical options and, accordingly, also requires appropriate pain management. There are established risk factors for severe postoperative pain that should be identified and considered in the perioperative management. The main risk factors and existing recommendations are presented in this article. Patients at risk should be identified before surgery. It is important that perioperative pain management is implemented in the treatment plan as part of an interdisciplinary cooperation to identify and address the risks as early as possible.

[The "Nationaler Kompetenzbasierter Lernzielkatalog Medizin NKLM 2.0"-Implications for medical education in ophthalmology]

BACKGROUND

The Masterplan Medicine 2020 has been passed by German authorities in 2017 and will be the basis for future developments in teaching and medical education in Germany. The "Nationaler Kompetenzbasierter Lernzielkatalog" NKLM as a learning target index will be the substructure in terms of its content.

METHOD

The NKLM 2.0 has been finalized in 2021. The basic concept of skill-related learning will replace the pure teaching of medical facts. Physician-patient communication will be a central issue. The structure of the NKLM 2.0 is presented and the main topics for teaching in ophthalmology are discussed.

RESULTS

The main chapters of the NKLM 2.0 that are directly related to topics in ophthalmology are chapter V medical conditions, chapter VI diseases, chapter VII comprehensive learning targets and chapter VIII comprehensive competences.

CONCLUSION

New teaching standards in ophthalmology need to include the topics and learning targets of the NKLM 2.0, as the NKLM will be legally binding in the future. It should be the basis but not exclusively, to improve educational standards in ophthalmology.

[Ocular alterations in patients with Alport syndrome-An update]

BACKGROUND AND OBJECTIVE

Alport syndrome (AS) is a rare hereditary systemic disease that results in alterations of the kidneys, inner ear, and various structures of the eye. It is caused by mutations in one of the genes encoding collagen type IV. In recent years, new and innovative imaging techniques have added characteristics of ocular alterations in AS and provided new insights, including into the pathogenesis of the disease. The aim of this paper is to provide an overview of the current knowledge of ocular changes in AS, as well as to present the Alport ocular pass.

METHOD

Narrative review article.

RESULTS

Ocular manifestations of AS include changes in the cornea, lens, and retina. Specifically, posterior polymorphic corneal dystrophy, anterior lenticonus (pathognomonic for AS), and various retinal changes have been described, which have been further characterized in recent years by newer imaging techniques. In particular, foveal changes in AS may present as both a thickened central retina in the context of foveal hypoplasia or a staircase-like thinning of the fovea. Both lesions could provide further insights into the role of type IV collagen in ocular structures.

CONCLUSION

The AS can manifest in various structures of the eye. The staircase-like changes of the central retina in AS patients indicate the important role of collagen type IV in the homeostasis and regular function of the inner retinal layers. The often mild foveal hypoplasia may provide clues to the role of collagen type IV in retinal embryogenesis. While anterior lenticonus is pathognomonic for AS and can be treated easily by refractive lens exchange, the only option currently available for retinal alterations is close follow-up and, if necessary, treatment of systemic complications of AS.

Central retinal artery occlusion - detection score

Purpose

To investigate the sensitivity and specificity of central retinal artery occlusion (CRAO)-Detection Score in diagnosing CRAO via questionnaire and without fundoscopy.

Methods

This prospective study enrolled 176 emergency patients suffering from acute visual loss, of whom 38 were suffering from CRAO. Before conducting any examination, we administered our questionnaire containing six questions, followed by a thorough ophthalmologic examination to make the diagnosis. Statistical analysis involved a LASSO penalised multivariate logistic regression model.

Results

Our receiver operating characteristic (ROC) analysis based on a LASSO penalised multivariate logistic regression model showed an area under the curve (AUC) of 0.9 - three out of six questions were selected by LASSO. Interestingly, the unweighted ROC analysis of only two questions (Short CRAO-Detection Score) yielded similar results with an AUC of 0.88. The short CRAO-Detection Score of 2 yielded 14% (4/28) false positive patients.

Conclusion

This prospective study demonstrates that a high percentage of CRAO patients are detectable with a questionnaire. The CRAO-Detection Score might be used to triage patients suffering acute visual loss, which is important as intravenous fibrinolysis seem to be time-dependent to be effective.

[Ischemia and laser photocoagulation in retinal vein occlusion]

BACKGROUND

Retinal vein occlusions (RVO) are associated with retinal ischemia to a highly variable extent. An ischemic retina may lead to the development of neovascularization and further to secondary complications such as neovascular glaucoma, vitreous hemorrhage or tractional retinal detachment. Numerous factors such as vascular endothelial growth factor (VEGF) and other cytokines are produced in the ischemic area, which cause macular edema. Before the introduction of intravitreal drug injections (IVI), retinal laser photocoagulation was the leading form of treatment. Macular laser photocoagulation was applied in the form of focal laser or grid laser in patients with branch retinal vein occlusion (BRVO) to treat macular edema. In patients with ischemic RVO, panretinal laser photocoagulation (PRP) was recommended for treatment of secondary neovascular complications. The value of laser treatment in the management of patients with RVO changed after the introduction of IVI treatment.

AIM

This article presents a review of the current study results and the recommendations for performing laser photocoagulation of the central and peripheral retina in patients with RVO.

CONCLUSION

Conventional focal or grid laser photocoagulation has been replaced by IVI treatment in the management of macular edema secondary to BRVO; however, macular laser treatment can still be considered in patients with BRVO if the macular edema persists despite the use of available IVI drugs. The use of central laser photocoagulation in these cases is based on the findings of fluorescein angiography. Disseminated panretinal laser photocoagulation is still indicated in RVO patients who have large areas of nonperfusion, have developed neovascularization and/or late complications. Targeted laser photocoagulation of the peripheral areas of nonperfusion has recently been recommended by several authors and is expected to improve not only the visual outcome of IVI treatment, but more importantly to also reduce the duration of treatment and the number of re-injections needed. Clear evidence for targeted laser treatment is not yet available and is a focus of currently ongoing prospective randomized studies.

Association between laser flare photometry and symptom duration in primary rhegmatogenous retinal detachment

PURPOSE

The purpose of this study was to investigate preoperative blood-ocular barrier disruption via laser flare photometry (LFP) in patients diagnosed with rhegmatogenous retinal detachment (RRD), and to analyse possible associations with symptom duration and anatomical parameters.

METHODS

We retrospectively analysed consecutive patients presenting with RRD at a single centre between January 2016 and March 2020. LFP was performed in both eyes after pupillary dilatation prior to RRD surgery. Symptom duration, extent of retinal detachment, and lens status were assessed. For statistical analysis, we carried out the unequal variances t test and Welch's analysis of variance (ANOVA).

RESULTS

We included 373 eyes of 373 patients (mean age 63.96 years ± 10.29; female:male ratio 1:1.8). LFP values quantified in photon count per millisecond (pc/ms) increased with longer symptom duration when comparing patients with a symptom duration of 0-3 days (n = 158; 9.25 ± 6.21 pc/ms) and ≥ 4 days (n = 215; 11.97 ± 11.58 pc/ms; p = 0.004). LFP values also rose with the number of retinal quadrants affected by RRD (1 quadrant, 6.82 ± 4.08 pc/ms; 2 quadrants, 10.08 ± 7.28 pc/ms; 3 quadrants, 12.79 ± 7.9 pc/ms; 4 quadrants, 31.57 ± 21.27 pc/ms; p < 0.001), macula off status (macula on, 8.89 ± 6.75 pc/ms; macula off, 12.65 ± 11.66 pc/ms; p < 0.001), and pseudophakic lens status (pseudophakia, 12.86 ± 9.52 pc/ms; phakia: 9.31 ± 9.67 pc/ms; p < 0.001).

CONCLUSION

In RRD patients, blood-ocular barrier disruption quantified by LFP is associated with the duration of symptoms and the disease's anatomical extent. These results warrant further investigation of the potential clinical use of LFP in RRD.

Incidence and risk factors for macular oedema after primary rhegmatogenous retinal detachment surgery: a prospective single-centre study

PURPOSE

To assess the incidence of cystoid macular oedema (CME) diagnosed by spectral domain optical coherence tomography (SD-OCT) after primary rhegmatogenous retinal detachment (RRD) surgery.

METHODS

From April 2016 to October 2017, 150 eyes of 150 patients presenting with primary RRD were included consecutively in this prospective single-centre study. Patients with the following characteristics were excluded: previous vitreoretinal surgery, combined cataract surgery, preoperatively presentation with any intraocular or systemic inflammatory condition, visible macular oedema or epiretinal membrane (ERM) on funduscopy. SD-OCT (Spectralis, Heidelberg Engineering) was conducted 3 and 6 weeks after surgery.

RESULTS

One hundred and twenty-eight of the 150 patients completed the study, of whom 107 (age: 61.7 ± 11.5 years, mean ± SD) showed successful retinal attachment during follow-up visits. The most frequent operation method was scleral buckling (54.2%), followed by vitrectomy (25.2%) and the combination of both techniques (20.6%). Postoperative SD-OCT revealed CME, neurosensory detachment and ERM in 18.7, 31.8 and 32.7% of all cases, respectively. The risk of postoperative CME was significantly elevated in patients with ERM (42.9 versus 6.9%, p < 0.001). In addition, patients with initial detachment of the macula had more postoperative CME (26.5 versus 11.1%, p = 0.044). BCVA improvement was significantly lower in patients with CME compared to patients without 6 weeks after surgery for macula-on RRD.

CONCLUSIONS

This prospective study confirmed that postoperative CME is a frequent complication after RRD surgery; we identified ERM and macula-off RRD as potential risk factors. As CME potentially delays visual recovery, postoperative follow-ups should include SD-OCT.

Risk Factors for Severe Bleeding Complications in Glaucoma Surgery and the Role of Antiplatelet or Anticoagulant Agents

Purpose

To evaluate the influences and risk factors for severe bleeding complications during glaucoma surgery, and to investigate the role of antiplatelet (AP) and anticoagulant (AC) agents.

Methods

This prospective study enrolled patients undergoing trabeculectomy, trabeculotomy (with Trabectome® or Kahook Dual Blade®), viscocanaloplasty and Ahmed or Baerveldt implants. Bleeding severity was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and one day later, the incidence and severity of bleeding events was documented on a standardized form. A grade ≥3 was defined as severe bleeding. The influence of known systemic disorders, the type of anesthesia, surgical procedure, intraoperative blood pressure, and the use of or change in AP or AC agents on intraoperative bleeding were analyzed.

Results

Data from 89 eyes undergoing glaucoma procedures were included (age 71.3y ± 10.5). We observed severe intraoperative bleeding in 8 eyes (9%) and found that concomitant diseases such as the history of a deep vein thrombosis or peripheral arterial occlusive disease, and the type of surgical procedure (trabeculectomy and viscocanaloplasty) were significantly associated with severe bleeding events. By contrast, the use of AP/ AC agents had no significant influence on severe intraoperative bleeding events.

Conclusion

According to the results of our study cohort, glaucoma procedures entailing scleral manipulations (trabeculectomy and viscocanaloplasty) and concomitant diseases such as the history of a deep vein thrombosis or peripheral arterial occlusive disease influence the risk of severe intraoperative bleeding events, we detected no increased risk related to concomitant antiplatelet and/ or anticoagulant medication use.

Influence of the Size of the Foveal Avascular Zone on Functional and Morphological Parameters in Patients with Early-Stage Diabetic Retinopathy

Purpose

To correlate functional and morphological parameters with foveal avascular zone’s (FAZ) size in diabetic patients with mild to moderate stage nonproliferative diabetic retinopathy.

Methods

Monocentric and prospective study of a consecutive case series of diabetic patients. Medical history, best corrected visual acuity (BCVA), best corrected high/low contrast visual acuity (BChcVA/BClcVA), mean sensitivity (MS) and mean defect (MD) in central visual field testing, and FAZ size in fluorescein-angiography (FAG) were recorded. Macular thickness (central point thickness CPT, central subfield thickness CST) and volume measurements (central subfield volume CSV, total macular volume) were taken from SD-OCT (6x6mm ETDRS-grid). Groups were categorised as presenting FAZ sizes smaller (G1) or larger (G2) than 0.35mm². Smallest (Q1) and largest quartiles (Q3) were also compared.

Results

Thirty-six of 40 patients were included. MS differed significantly between G1 (n = 6) and G2 (n = 30), and BChcVA/BClcVA as well as TMV correlated significantly with FAZ size in correlation analysis. Mean HbA1c tended to be lower in G1 than G2. Patients in G1 were slightly older than in G2. Treatment period with insulin was shorter in G1/Q1 than in G2/Q3. CPT and TMV were lower in G1/Q1 than in G2/Q3. Our analysis of the FAZ in terms of patient age, HbA1c, disease duration and insulin therapy duration revealed no significance. That lack of significance also applies to BCVA, MS, MD, CPT, CST and CSV.

Conclusion

As significantly associated, contrast sensitivity, central visual field parameters and potentially retinal thickness or volume seem to be suitable to detect early macular ischaemia. However, we failed to establish any correlation between FAZ and BCVA.

A randomized, open-label, multicenter study of switching to brolucizumab with or without a loading dose for patients with suboptimal anatomically controlled neovascular age-related macular degeneration-the FALCON study

Background

Treatment initiation with brolucizumab, a new potent anti-vascular endothelial growth factor (VEGF) agent, is typically performed with three monthly injections (loading dose) and has been well studied in treatment-naïve patients. However, no clinical data are available yet on whether or not anti-VEGF pretreated patients also benefit from a loading dose. In the clinical setting, different heterogeneous treatment patterns are used as no clinical trial has addressed this so far in a head-to-head comparison. Therefore, the FALCON study is investigating whether patients with unsatisfactory response to previous anti-VEGF treatments benefit from a loading dose at the switch to brolucizumab treatment.

Methods

FALCON is a 52-week, two-arm, randomized, open-label, multicenter, multinational study in patients with residually active neovascular age-related macular degeneration (nAMD) who will be randomized 1:1 and started with brolucizumab 6 mg loading (three monthly loading doses) or brolucizumab 6 mg non-loading (one initial injection) and consecutive treatment every 12 weeks, respectively. The primary objective is to demonstrate non-inferiority of the non-loading vs. loading arm in mean change of best-corrected visual acuity (BCVA) from baseline to the mean value at week 40 to week 52. Secondary objectives include the assessment of anatomical outcomes, treatment intervals, safety and tolerability.

Results

FALCON will be the first study to assess treatment initiation with an anti-VEGF agent in a switch situation with or without loading dose in patients with nAMD.

Conclusions

The results will support the optimization of treatment of patients with previous unsatisfactory anti-VEGF response. Therefore, we expect to see an impact on current clinical practice which has been established for more than a decade.

Trial registration

Clinicaltrials.gov: NCT04679935, date of registration—22-Dec 2020; EUDRACT number: 2019–004763-53, date of registration—03 Dec 2019.

[Avoiding mistakes in anti-VEGF intravitreal injection therapy]

Intravitreal injection (IVI) of drugs for treatment of various macular diseases is now one of the most frequently performed surgical procedures worldwide. As mostly chronic diseases are treated, the indications for treatment often mean a continuous treatment over years with a corresponding effort regarding spatial, personnel and financial resources. The diagnosis and indications for treatment are nowadays mainly made by spectral domain optical coherence tomography (SD-OCT). The ability to clinically assess and evaluate a fluorescence angiography is less practiced, although these are still a component of the indications for intravitreal injections. Therefore, it can happen that despite all diligence patients may receive anti-vascular endothelial growth factor (VEGF) treatment, sometimes permanently, based on a misinterpretation of the macular diagnosis or disease activity and these indications, once made, are rarely questioned or retracted. Therefore, the aim of this manuscript is to point out possible and typical misinterpretations in the indications or continuation of IVI treatment with anti-VEGF by means of case studies and to sensitize for differential diagnoses.

[Collaboration with clinical research organizations : Introduction of a questionnaire for clinical study centers]

Clinical trials with pharmaceuticals or medical devices make complex demands on sponsors and participating centers. During the past two decades, sponsors have increasingly delegated regulatory and organizational tasks to clinical research organizations (CRO). As a rule, these companies are the main interface for the collaboration with the participating study centers. The main purpose of the participation is the support of the study centers for achieving an optimal study quality. The study centers involved in the DOG working group on clinical study centers perceived varying experiences in the collaboration with CROs. In the future these experiences will be systematically assessed at the participating study centers and analyzed by the coordinating investigator. Reflecting these experiences to the respective CROs and the delegating sponsors will contribute to the quality of support by CROs and herewith to the quality of clinical trials. This paper presents which areas of collaboration will be assessed and analyzed.

Predicting the individual probability of macular hole closure following intravitreal ocriplasmin injections for vitreomacular traction release using baseline characteristics

The primary objective was to create and establish a new formula that predicts the individual probability of macular hole closure for eyes with full thickness macular holes (FTMH) accompanied by vitreomacular traction (VMT) which received enzymatic vitreolysis using intravitreally administered ocriplasmin. The secondary objective was to evaluate the forecast reliability of a previously published formula for VMT resolution in VMT-only eyes (Odds_IVO-Success = e^Intercept× OR^years× OR^ln(µm); Probability_IVO-Success = Odds_IVO-Success/(Odds_IVO-Success + 1)) on VMT resolution using the current dataset of eyes with FTMH accompanied by VMT. Retrospective analysis of the OASIS, ORBIT, and INJECT-studies. Patients with FTMH and VMT with complete information (n = 213) were included. The effect of gender, age, FTMH diameter, lens status and the presence of epiretinal membranes (ERM) on FTMH closure was assessed using separate univariate logistic regression analyses. With regard to VMT release separate univariate regression analyses were carried out and results were compared with formerly published data of VMT resolution in eyes with VMT only. Overall, 126 eyes (63%) experienced VMT resolution within 28 days. Younger age (p < 0.0001) and VMT diameter (p = 0.041) had a significant impact on VMT release. Overall, 81 eyes (38%) treated with ocriplasmin showed FTMH closure within 28 days. Univariate analysis of the different predictors analyzed revealed that FTMH diameter < 250 µm had a significant impact on treatment success (p = 0.0495). It was not possible to calculate and establish a new multivariate formula that can predict the individual FTMH closure probability for eyes with FTMHs and VMT. However, the results of VMT release prediction in eyes with FTMHs accompanied by VMT matched the prediction of VMT release in eyes with VMT only when using the previously published formula. All in all, predictors for calculating the individual probability of VMT resolution on the one hand and FTMH closure on the other hand are different suggesting diverse pathophysiological mechanisms.

Diagnosing Central Retinal Artery Occlusion (CRAO) without Fundus Examination

In the field of ophthalmology, central retinal artery occlusion is still one of the unsolved pathologies, as there is no widely accepted evidence-based therapeutic concept. Meta-analysis suggests that intravenous fibrinolysis might help to improve the outcome if performed within the first 4.5 hours after symptom onset. However, this short window of opportunity is often missed due to delays during diagnostic testing (e.g. time elapsed before performance of an ophthalmological examination) or patient-processing (referring the patient to a specialized medical facility). This article presents a diagnostic tool in the form of a simple questionnaire, comprising a medical history and examinations, which could help to minimize the time required to initiate the appropriate treatment.

COVID-19 Outbreaks in Settings With Precarious Housing Conditions in Germany: Challenges and Lessons Learned

Two COVID-19 outbreaks occurred in residential buildings with overcrowded housing conditions in the city of Göttingen in Germany during May and June 2020, when COVID-19 infection incidences were low across the rest of the country, with a national incidence of 2.6/100,000 population. The outbreaks increased the local incidence in the city of Göttingen to 123.5/100,000 in June 2020. Many of the affected residents were living in precarious conditions and experienced language barriers. The outbreaks were characterized by high case numbers and attack rates among the residents, many asymptomatic cases, a comparatively young population, and substantial outbreak control measures implemented by local authorities. We analyzed national and local surveillance data, calculated age-, and gender-specific attack rates and performed whole genome sequencing analysis to describe the outbreak and characteristics of the infected population. The authorities' infection control measures included voluntary and compulsory testing of all residents and mass quarantine. Public health measures, such as the general closure of schools and a public space as well as the prohibition of team sports at local level, were also implemented in the district to limit the outbreaks locally. The outbreaks were under control by the end of June 2020. We describe the measures to contain the outbreaks, the challenges experienced and lessons learned. We discuss how public health measures can be planned and implemented through consideration of the needs and vulnerabilities of affected populations. In order to avoid coercive measures, barrier-free communication, with language translation when needed, and consideration of socio-economic circumstances of affected populations are crucial for controlling infectious disease transmission in an outbreak effectively and in a timely way.

Acute macular neuroretinopathy (AMN) following COVID-19 vaccination

Purpose

To describe a case of acute macular neuroretinopathy (AMN) in a 23-year-old Caucasian female after a COVID-19 vaccination (Vaxzevira).

Observations

Our patient perceived visual symptoms in both eyes one day after COVID-19 vaccination. Hyporeflective petalloid shaped perifoveal lesions appeared in infrared reflectance (IR) imaging, and Spectral domain-optical coherence tomography (SD-OCT) revealed structural alterations of outer retinal layers that resulted in persistent disruption of the ellipsoid zone (EZ) and the interdigitation zone (IZ).

Conclusions and importance

We report a novel association between AMN and COVID-19 vaccination. In addition to a febrile infection and oral contraception, previous vaccination should also be considered a potential risk factor for AMN.

Risk Factors for Severe Bleeding Complications in Vitreoretinal Surgery and the Role of Antiplatelet or Anticoagulant Agents

PURPOSE

To evaluate the influences and risk factors for severe bleeding complications during vitreoretinal surgery and to investigate the role of antiplatelet and anticoagulant agents.

DESIGN

Prospective trial.

PARTICIPANTS

Patients undergoing vitreoretinal surgery.

METHODS

The procedures included were pars plana vitrectomy and scleral buckling. We developed a uniform classification to grade the bleeding severity. Bleeding was graded on an ordinal scale ranging from 0 to 5. Immediately after surgery and 1 day later, the incidence and the severity of bleeding events was documented on a standardized form. A grade of 3 or more was defined as severe bleeding. Furthermore, the influence of known systemic disorders before surgery, the type of anesthesia, type of surgical procedure, intraoperative blood pressure, and the use or change of antiplatelet or anticoagulant agents on intraoperative bleeding was analyzed.

MAIN OUTCOME MEASURES

Incidence and risk factors for severe intraoperative bleeding events.

RESULTS

Data from 374 eyes undergoing vitreoretinal procedures were included in our study (mean age, 67.6 ± 12.9 years). A severe intraoperative bleeding event was observed in 15 eyes (4%). We found that concomitant diseases such as diabetes mellitus and carotid artery stenosis, the presence of diabetic retinopathy, younger age, and scleral buckling combined with a transscleral puncture were associated significantly with severe bleeding events. By contrast, use of antiplatelet or anticoagulant agents, or both, had no significant influence on severe intraoperative bleeding events.

CONCLUSIONS

Although external manipulations during buckling surgery (e.g., drainage of subretinal fluid) and concomitant diseases such as diabetes mellitus and carotid artery stenosis influences the risk of severe intraoperative bleeding events, we did not detect an increased risk related to coexisting antiplatelet or anticoagulant medication use, or both.

[Anticoagulation and platelet aggregation inhibition : What needs to be considered in the ophthalmological practice]

Several eye diseases requiring surgical intervention occur predominantly in elderly. Therefore, there is a significant co-incidence with systemic co-morbidities, which often do require anti-coagulation. There are several approaches to influence hemostasis pharmacologically. The number of options has increased substantially due to introduction of new drugs. This article provides an overview on the option range and gives insight, why this is of importance from the perspective of internal medicine. In addition, the basic principles of adjusting the therapy is being reviewed. Furthermore, the pharmacological inhibition of hemostasis in the context of eye surgery is being discussed. Available literature is analyzed to understand the necessity to interrupt or change the anti-coagulation for eye surgery.

APOSTEL 2.0 Recommendations for Reporting Quantitative Optical Coherence Tomography Studies

OBJECTIVE

To update the consensus recommendations for reporting of quantitative optical coherence tomography (OCT) study results, thus revising the previously published Advised Protocol for OCT Study Terminology and Elements (APOSTEL) recommendations.

METHODS

To identify studies reporting quantitative OCT results, we performed a PubMed search for the terms "quantitative" and "optical coherence tomography" from 2015 to 2017. Corresponding authors of the identified publications were invited to provide feedback on the initial APOSTEL recommendations via online surveys following the principle of a modified Delphi method. The results were evaluated and discussed by a panel of experts and changes to the initial recommendations were proposed. A final survey was recirculated among the corresponding authors to obtain a majority vote on the proposed changes.

RESULTS

A total of 116 authors participated in the surveys, resulting in 15 suggestions, of which 12 were finally accepted and incorporated into an updated 9-point checklist. We harmonized the nomenclature of the outer retinal layers, added the exact area of measurement to the description of volume scans, and suggested reporting device-specific features. We advised to address potential bias in manual segmentation or manual correction of segmentation errors. References to specific reporting guidelines and room light conditions were removed. The participants' consensus with the recommendations increased from 80% for the previous APOSTEL version to greater than 90%.

CONCLUSIONS

The modified Delphi method resulted in an expert-led guideline (evidence Class III; Grading of Recommendations, Assessment, Development and Evaluations [GRADE] criteria) concerning study protocol, acquisition device, acquisition settings, scanning protocol, funduscopic imaging, postacquisition data selection, postacquisition analysis, nomenclature and abbreviations, and statistical approach. It will be essential to update these recommendations to new research and practices regularly.

Expert Opinion on Management of Intraocular Inflammation, Retinal Vasculitis, and Vascular Occlusion after Brolucizumab Treatment

PURPOSE

Recent reports have described a spectrum of uncommon findings of intraocular inflammation (IOI), retinal vasculitis, or retinal vascular occlusion in patients with neovascular age-related macular degeneration (nAMD) treated with intravitreal injection (IVI) of brolucizumab. We present guidance on the clinical presentation of this spectrum and propose recommendations for management of these events.

DESIGN

PubMed literature review and expert opinion panel.

PARTICIPANTS

A working group of international medical experts and Novartis medical personnel.

METHODS

The working group deliberated on the clinical presentations and used a 3-pronged approach to develop management recommendations based on (1) critical appraisal of scientific literature; (2) clinical insights from the HAWK and HARRIER trials, postmarketing reports, and assessments from an independent Safety Review Committee (SRC); and (3) their clinical experience.

MAIN OUTCOME MEASURES

Management recommendations for a spectrum of ocular inflammatory events after treatment with brolucizumab or other anti-vascular endothelial growth factors (VEGFs).

RESULTS

Based on insights gained from the available information and the expertise of the contributors, recommendations were proposed for ocular examinations, imaging modalities, and treatment strategies for management of this spectrum of events. Patients should be educated to promptly report any relevant or persistent symptoms after IVI to facilitate timely intervention. Patients diagnosed with IOI should be evaluated for concomitant retinal vasculitis or retinal vascular occlusive events. Clinical examination can be augmented with multimodal imaging techniques, including widefield imaging, fluorescein angiography (with peripheral sweeps), and OCT. Once confirmed, the ongoing brolucizumab treatment should be suspended and intensive treatment with potent corticosteroids (topical, subtenon, intravitreal, or systemic) is recommended, which may be supplemented with other treatment strategies depending on the severity. Based on the clinical outcome of these events, individualized treatment with locally available standard of care should be considered for the underlying nAMD.

CONCLUSIONS

These recommendations emphasize the need for early diagnosis, prompt and timely intervention, intensive treatment, and frequent monitoring to minimize the risk of progression of these events. The proposed recommendations may facilitate a consistent management approach of this spectrum of ocular inflammatory events should they arise in nAMD after treatment with brolucizumab or other anti-VEGFs.

Reliability of Subjective Assessment of Spectral-Domain OCT Pathologic Features by Multiple Raters in Retinal Vein Occlusion

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Diagnosing SARS-CoV-2 with Antigen Testing, Transcription-Mediated Amplification and Real-Time PCR

This study was performed as a head-to-head comparison of the performance characteristics of (1) two SARS-CoV-2-specific rapid antigen assays with real-time PCR as gold standard as well as (2) a fully automated high-throughput transcription-mediated amplification (TMA) assay and real-time PCR in a latent class analysis-based test comparison without a gold standard with several hundred samples in a low prevalence "real world" setting. Recorded sensitivity and specificity of the NADAL and the LumiraDx antigen assays and the Hologic Aptima SARS-CoV-2 TMA assay were 0.1429 (0.0194, 0.5835), 0.7644 (0.7016, 0.8174), and 0.7157 (0, 1) as well as 0.4545 (0.2022, 0.7326), 0.9954 (0.9817, 0.9988), and 0.9997 (not estimable), respectively. Agreement kappa between the positive results of the two antigen-based assays was 0.060 (0.002, 0.167) and 0.659 (0.492, 0.825) for TMA and real-time PCR. Samples with low viral load as indicated by cycle threshold (Ct) values > 30 were generally missed by both antigen assays, while 1:10 pooling suggested higher sensitivity of TMA compared to real-time PCR. In conclusion, both sensitivity and specificity speak in favor of the use of the LumiraDx rather than the NADAL antigen assay, while TMA results are comparably as accurate as PCR, when applied in a low prevalence setting.

Ophthalmic Outpatient and Inpatient Care Under Pandemic Conditions: Hygiene, Triage and New Challenges

BACKGROUND

The progression of the COVID-19 pandemic has caused significant changes in the environment for outpatient and inpatient care in ophthalmology, with limitations on access to medical care but also new observations and challenges. We now describe major developments in recent months and provide an outlook on the expected consequences.

METHODS

PubMed literature search, clinical survey.

RESULTS

To date, the course of the COVID-19 pandemic has been characterised by several new but overall rare ocular manifestations, the ophthalmological shared management of COVID-19 patients on intensive care units, and a significant decrease in case numbers, associated with an increase in case severity and relative proportion of emergencies, as a result of delayed presentation of patients and reduced treatment adherence. With the introduction of hygiene measures and infection control procedures, ophthalmic patient care was maintained - including emergencies and urgent treatments. Due to the extensive postponement of elective surgeries, scarce therapeutic and health care professional resources, and the prioritisation of critically ill patients from other specialties, there is a reasonable likelihood that urgent treatments will be delayed as infection rates rise.

CONCLUSION

Outpatient and inpatient care in ophthalmology during the COVID-19 pandemic is primarily accompanied by additional organisational or medical challenges and a decline in case volume. Although to date emergency and urgent ophthalmic treatments have been maintained, long-term persistence of pandemic conditions will require additional strategies to provide continuation of ophthalmic care at the required level.

[Unilateral optic atrophy in a 9-year-old patient]

Ein 9‑jähriger Patient stellte sich aufgrund einer seit 2 Wochen zufällig bemerkten Sehminderung auf dem linken Auge vor. Funduskopisch waren neben einer leichten Vitritis eine blasse Papille, enggestellte Gefäße und eine Reflexvermehrung der Netzhautoberfläche sichtbar. In der Blutuntersuchung waren die Werte bis auf eine Eosinophilie und einen erhöhten Immunglobublin E(IgE)-Antikörpertiter normal.

[Advertising or information in ophthalmology? : Scientific evaluation of a YouTube sample]

Hintergrund

Trotz der Liberalisierung des Heilmittelwerbegesetzes ist anpreisende, irreführende oder vergleichende Werbung nach wie vor berufswidrig. Angesichts des zunehmenden Engagements von Finanzinvestoren und der Ökonomisierung in der Augenheilkunde sollte diese Arbeit prüfen, welche Aussagen in offen zugänglichen Videos der YouTube-Plattform getroffen werden.

Methode

Mit den Suchbegriffen „Augenarzt“, „Augenärztin“ und „Augenzentrum“ sowie vordefinierten Kriterien (deutsche Herkunft, Audiospur mit Text, Dauer >1 min) wurden Videos identifiziert und in eine anonymisierte Textform transkribiert. Mittels eines eigens entwickelten Fragebogens wurden die Einzelaussagen daraufhin einer kritischen Prüfung durch jeweils 3 Experten unterzogen sowie Klarheit, Relevanz und Vollständigkeit bewertet. Parallel wurden Laien abgefragt, wie überzeugend, verständlich und vollständig sie die Informationen bewerten und ob sie sich von den Ärzten behandeln lassen würden.

Ergebnisse

Von 68 Videos erfüllten 30 die definierten Einschlusskriterien; 46 % der Videos thematisierten Verfahren der refraktiven Chirurgie. Aus Sicht der Experten waren mindestens 11,8 % der Einzelaussagen vollständig falsch oder wenig korrekt. Über 80 % der Filme stellten Informationen unvollständig dar. So wurden z. B. peri- und postoperative Komplikationen nur von 3 Filmen angesprochen. Laien bewerteten die Texte recht uneinheitlich und konnten nicht die Videos identifizieren, die aus Sicht der ophthalmologischen Fachärzte problematische Aussagen enthielten. Es wurden Konflikte mit den rechtlichen Anforderungen an Werbung z. B. in der Verwendung entsprechender Superlative festgestellt. Eine ausgewogene Darstellung wie Alternativen zu den Behandlungsverfahren war kaum enthalten, die Verständlichkeit für Laien war verbesserungswürdig.

Schlussfolgerungen

Nur eine geringe Anzahl frei zugänglicher Videos bot aktuelle, wissenschaftlich fundierte und korrekte Informationen. Bisher berücksichtigen nur wenige Augenärzte die juristischen und moralischen Anforderungen an werbende Aussagen. Daher ergeben sich möglicherweise negative Auswirkungen auf das Berufsbild in der Öffentlichkeit, und Chancen zur Gesundheitsförderung bleiben ungenutzt.

Influence of pars plana vitrectomy for macular surgery on the medium term intraocular pressure

Purpose

To evaluate the long-term effect of 20 and 23 gauge pars plana vitrectomy (PPV) on intraocular pressure (IOP).

Methods

Study type: Monocentric retrospective cohort study. 249 eyes of 249 patients undergoing PPV due to epiretinal membrane (EM), idiopathic macular hole (IMH) or vitreoretinal traction (VT) were included. The fellow eye served as control. Exclusion criteria were factors known to influence the IOP, such as cataract surgery during follow-up, extended use of steroids, cryotherapy and silicone oil endotamponade. The relative change of IOP (operated vs. fellow eye) at 6–12 months after surgery was defined as primary endpoint. Secondary endpoints were the relative change of IOP at 3–6 and 12–24 months. Possible influencing cofactors were analysed using ANCOVA.

Results

The primary endpoint did not show a significant IOP reduction of the operated eye relative to the fellow eye (P = 0.089, n = 84). However, the IOP of the operated eye alone was significantly reduced at 6–12 and 12–24 months after surgery (-0.75 ± 2.80 and -1.22 ± 3.29 mmHg, P = 0.008 and 0.007, respectively). The IOP of the fellow eye was also significantly reduced at the 12–24 months period (-0.75 ± 2.73 mmHg, P = 0.008). In the subgroup analysis, sclerotomy size was a significant influencing cofactor, leading to lower IOP after 20G compared to 23G vitrectomy (P = 0.04).

Conclusion

Pars plana vitrectomy did not induce a significant long-term IOP reduction relative to the contralateral eye. However, we observed a IOP lowering potential in 20G vitrectomy.

[Impacts of the SARS-CoV-2 pandemic on ophthalmic care in Germany]

Hintergrund

Umfrage der „Kommission Sektorenübergreifende Augenheilkunde“ als gemeinsame Kommission der Deutschen Ophthalmologischen Gesellschaft (DOG) und des Berufsverbandes der Augenärzte Deutschlands (BVA) zu den Auswirkungen der SARS-CoV-2-Pandemie auf die ophthalmologische Versorgung in Deutschland.

Methoden

Online-basierte Umfrage.

Ergebnisse

Insgesamt wurden 1190 Fragebögen (teilweise) beantwortet. Die Ambulanz- bzw. Sprechstundentätigkeit in der Zeit vom 15.03. bis 15.04.2020 gaben 69 (5,8 %) Teilnehmer mit „uneingeschränkt“, 756 (63,5 %) mit „reduziert“ und 330 (27,7 %) als „ausschließliche Notfallversorgung“ an, unabhängig von der Art der Einrichtung. Ambulante Operationen waren in 68,0 % der Hauptabteilungen, 42,0 % der Belegabteilungen, 45,0 % der operativen MVZ und Gemeinschaftspraxen und 33,0 % der operativen Einzelpraxen notfallchirurgischen Eingriffen vorbehalten. Stationäre Eingriffe waren in 75,0 % der Belegabteilungen und in 71,0 % der Hauptabteilungen auf die Versorgung von Notfällen beschränkt. Die Fallzahlen dringlicher Indikationen und Notfälle waren mit Ausnahme der Endophthalmitis (+8,2 %) rückläufig: Amotio retinae (−34,8 %), Bulbusperforation (−7,3 %), Glaukomanfall (−17,8 %), ZAV und AION (−31 %), Sonstige (−30,9 %), perforierende Keratoplastik und Amnionmembrantransplantation (−59,1 %). Institutionelle oder berufspolitische Vorgaben (76,0 %) sowie Terminabsagen durch Patienten (84,0 %) waren der häufigste Grund für eine Einschränkung der ophthalmologischen Versorgung.

Schlussfolgerung

Während der Pandemie kam es initial zu einer erheblichen Reduzierung nichtdringlicher konservativer und chirurgischer Behandlungen, von der alle Bereiche der Augenheilkunde betroffen waren. Aufgrund der für COVID-19-Patienten benötigten Intensivkapazitäten waren insbesondere stationäre Behandlungen weitgehend auf Notfälle beschränkt. Die Versorgung ophthalmologischer Patienten einschließlich Notfällen und dringlicher Behandlungen konnte sektorübergreifend aufrechterhalten werden, wobei für beide Gruppen ein (deutlicher) Rückgang der Fallzahlen beobachtet wurde.

There is no intraocular affection on a SARS-CoV-2 - Infected ocular surface

Purpose

The presence of SARS-CoV-2 RNA in anterior chamber fluid and/or the vitreous in patients with SARS-CoV-2 RNA on the ocular surface is unclear. Knowledge about the infectious state of intraocular structures could influence the daily work of ophthalmic surgeons.

Observations

We analyzed ocular samples from a patient who had succumbed to COVID-19 pneumonia for the prevalence of SARS-CoV-2 RNA. We detected viral RNA in the ocular-surface samples on one swab and in one excidate from the conjunctiva. Samples from the anterior chamber and vitreous revealed no SARS-CoV-2 RNA.

Conclusions

SARS-CoV-2 can effectively be inactivated with standard disinfection agents. The now proven absence of SARS-CoV-2 in intraocular fluids could influence how ophthalmic surgeons work. Without having to account for the risk of a contagion via the anterior chamber and/or vitreous body, the surgical staff would require no additional, more elaborate protection.

An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study

PURPOSE

To study and compare the efficacy of different therapeutic options for the treatment of central serous chorioretinopathy (CSCR).

METHODS

This is a nonrandomized, international multicentre study on 1719 patients (1861 eyes) diagnosed with CSCR, from 63 centres (24 countries). Reported data included different methods of treatment and both results of diagnostic examinations [fluorescein angiography and/or optical coherent tomography (OCT)] and best-corrected visual acuity (BCVA) before and after therapy. The duration of observation had a mean of 11 months but was extended in a minority of cases up to 7 years. The aim of this study is to evaluate the efficacy of the different therapeutic options of CSCR in terms of both visual (BCVA) and anatomic (OCT) improvement.

RESULTS

One thousand seven hundred nineteen patients (1861 eyes) diagnosed with CSCR were included. Treatments performed were nonsteroidal anti-inflammatory eye drops, laser photocoagulation, micropulse diode laser photocoagulation, photodynamic therapy (PDT; Standard PDT, Reduced-dose PDT, Reduced-fluence PDT), intravitreal (IVT) antivascular endothelial growth factor injection (VEGF), observation and other treatments. The list of the OTHERS included both combinations of the main proposed treatments or a variety of other treatments such as eplerenone, spironolactone, acetazolamide, beta-blockers, anti-anxiety drugs, aspirin, folic acid, methotrexate, statins, vitis vinifera extract medication and pars plana vitrectomy. The majority of the patients were men with a prevalence of 77%. The odds ratio (OR) showed a partial or complete resolution of fluid on OCT with any treatment as compared with observation. In univariate analysis, the anatomical result (improvement in subretinal fluid using OCT at 1 month) was favoured by age <60 years (p < 0.005), no previous observation (p < 0.0002), duration less than 3 months (p < 0.0001), absence of CSCR in the fellow eye (p = 0.04), leakage outside of the arcade (p = 0.05) and fluid height >500 μm (p = 0.03). The OR for obtaining partial or complete resolution showed that anti-VEGF and eyedrops were not statistically significant; whereas PDT (8.5), thermal laser (11.3) and micropulse laser (8.9) lead to better anatomical results with less variability. In univariate analysis, the functional result at 1 month was favoured by first episode (p = 0.04), height of subretinal fluid >500 μm (p < 0.0001) and short duration of observation (p = 0.02). Finally, there was no statistically significant difference among the treatments at 12 months.

CONCLUSION

Spontaneous resolution has been described in a high percentage of patients. Laser (micropulse and thermal) and PDT seem to lead to significant early anatomical improvement; however, there is little change beyond the first month of treatment. The real visual benefit needs further clarification.

Reorganization of the perifoveal microvasculature after macular hole closure assessed via optical coherence tomography angiography

PURPOSE

To quantify short-term microvascular changes after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in patients with idiopathic macular hole (IMH) using optical coherence tomography angiography (OCTA).

DESIGN

Cohort Study.

PARTICIPANTS

This study included patients with IMH. Affected eyes were compared with fellow eyes.

METHODS

6 × 6 mm OCTA (Zeiss Angioplex, Zeiss Meditec, Dublin, CA, USA) images of the study eye and fellow eye were acquired one day before surgery, 4 weeks and 12 weeks after surgery. Microvascular alterations in the superficial and deep capillary plexus were assessed by measuring vessel density and the shortest distance to the surrounding vessels of all intercapillary pixels. Only vessels enclosed by an ETDRS Grid centered on the fovea were analyzed.

MAIN OUTCOME MEASURES

Change of vessel density and vessel distance to baseline.

RESULTS

OCTA images of the 15 study and 15 fellow eyes of 15 included patients (mean ± SD of age: 67.89 ± 5.2 years) were analyzed and revealed a significant increase in vessel density and decrease in vessel distance of the deep capillary plexus in study eyes 4 weeks after surgery compared to baseline. Our superficial capillary plexus findings were the inverse, namely a significant decrease in vessel density and increase in vessel distance. Postoperative microvascular changes proved to be closely associated with the extent of retinal thickness reduction in the perifoveal deep capillary plexus.

CONCLUSIONS

IMH closure after PPV and ILM peeling caused a significantly improved microvasculature in the deep capillary plexus, which may represent reorganized perifoveal microvasculature due to the regression of cystoid spaces.

[Development of a learning target index for ophthalmology]

BACKGROUND

Future developments of teaching in human medicine and ophthalmology emphasize the need of a learning target index to standardize and modernize education at German universities. The first measure is the elaboration of a learning target index of the German Ophthalmological Society (DOG).

METHOD

The masterplan medicine 2020 has been passed by German authorities in 2017 to restructure studies in human medicine at German universities according to a concept of skill-related learning objectives rather than based on factual knowledge. The executive committee of the DOG, together with all subsections, accepted the first version of the learning target index elaborated by the authors on 30 May 2016.

RESULTS

The learning target index for ophthalmology encompasses 25 chapters, whereby chapter 1 is dedicated to the investigation methods and treatment. Chapters 2-23 deal with the diseases and are subdivided according to definition and leading symptoms, pathogenesis as well as diagnostics and treatment. To correspond to the need to focus on core items individual chapters are introduced for glaucoma, diabetic retinopathy, age-related macular degeneration and retinal detachment. Differential diagnoses and main symptoms are dealt with in chapter 24, the epidemiology and causes of blindness in chapter 25. The depths of competence are presented for the groups of all students and the practical competence (depth of competence 3) is dealt with separately for semester students and students in the practical year.

CONCLUSION

This learning target index for ophthalmology is the first approved by the DOG and represents a first step to further improve medical education in ophthalmology at German universities. The new teaching standards for studies in human medicine related to the masterplan medicine 2020 reflect the need of a consented approach to improve educational standards in ophthalmology so that all topics in ophthalmology remains sufficiently represented despite the specification to focus on high priority core items.

[Ophthalmological student teaching-results of a survey at German universities]

BACKGROUND

The deployment of lecturers and different teaching strategies at German university eye clinics were assessed via a questionnaire.

METHODS

In an online questionnaire the lecturers at German university eye clinics were asked to answer a total of 28 questions. The questions had been agreed upon by the German Ophthalmological Society (DOG) teaching group.

RESULTS

A total of 30 lecturers from the 36 German university clinics answered the questionnaire (83%). At most of the locations, a half-year course during one semester is held with a median of 180 students taking the course. The median number of teaching hours per semester and clinic was 112 h. Whereas financial support for lecturing is available from the faculty in many locations, only six clinics also allotted lecturers time to organize the teaching. The practical examinations already established in other subjects (objective structured clinical examination, OSCE) are carried out at roughly every third clinic.

CONCLUSION

This survey revealed a high level of commitment on the part of lecturers at German university eye clinics. The diversity of local conditions poses a challenge to ensuring comparable teaching standards in Germany. Support from the respective clinic administration/faculty could be improved at many locations.